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Opinion and debate

We recently had a homicide inquiry in our trust. The events around the release of the report made for a demoralising experience. The visible pain in the families of the victim and the perpetrator caused by the tragedy was heart-rending. As Medical Director, I also saw at first hand the powerful impact on the members of the team involved, my colleagues in general, the trust management and the health authority, all of whom strive to provide effective mental health services in one of the most deprived areas in the country. There were also political influences, especially the need to be seen not to tolerate poor performance. Allusions to disciplinary issues were not infrequent. We all found it very disturbing. I was forced to think a lot about homicide inquiries and became increasingly struck by a growing number of internal contradictions. I started making notes to help order my thoughts. I offer for discussion some conclusions using this inquiry (Scotland et al, 1998) as an example.

To cram 2000 years of the history of psychiatry into the space allowed me in this paper is like attempting to transcribe the Lord's Prayer onto the back of a postage stamp. It's well-nigh impossible, but it can be done. Fortunately for me, the task has been made infinitely less difficult by the fact that psychiatry as an organised, independent discipline dates back only as recently as the last decades of the 18th century and its history is, therefore, correspondingly short. So, I'll begin there.

Of all the medical specialities, psychiatry seems the most resistant to change in the face of rapidly evolving technology. Yet psychiatry could become the speciality most revolutionised by advanced technology in the new millennium. If the following predictions for psychiatry in the next 1000 years appear difficult to believe, imagine what might have been the reaction of those living in 999 to being told what would happen by 1999. Back then the profession of medicine as we understand it did not even exist, neither did there appear to be any institutions devoted to the care of the mentally ill. Indeed, in 1000 years' time from now, we might yet return to a similar situation in both these respects!

This survey is the first UK study of trainee psychiatrists' experiences of patient suicide. One hundred and three senior and specialist registrars in psychiatry working in Scotland completed the questionnaire, representing an 81% response rate.

Results

Almost half (47%) had experienced suicide of a patient in their care or otherwise known to them (e.g. through on-call experiences). Although only 28% recalled previous training on issues to consider following a suicide, all of these doctors found this to be of value. Many reported that patient suicide had a deleterious impact on their personal and professional lives. The most valuable supports were informal, and the trainees' consultants appeared particularly well placed to offer support and advice.

Clinical Implications

Many trainee psychiatrists experience the suicide of a patient. Such experiences have potential for adverse effects on doctors' professional practice and personal life. Greater availability of training in this area would allow trainees to be better prepared for such an event. Trainees' consultants have a pivotal role to play in providing appropriate advice and support after a patient suicide.

To examine antidepressant prescribing in a general medical hospital in the UK. The data used were extracted from a prescription database prospectively maintained by the hospital pharmacy. All prescriptions of antidepressants over a five-year period, both new and continuation, were recorded.

Results

During the study period there were 2037 prescriptions of tricyclic antidepressants. Only 18% of these prescriptions were at conventional therapeutic doses. This compared with 773 prescriptions of selective serotonin reuptake inhibitors, 70% of which were at conventional therapeutic doses. It is shown that antidepressants were prescribed at a dose in accordance with the smallest tablet size available.

Clinical Implications

We suggest that reformulation of tablets to allow one tablet daily prescribing may lead to improved antidepressant prescribing.

Special articles

At a recent regional meeting of consultant psychiatrists I did something rather irregular. I admitted I frequently take a lunch break. It felt like a confession having just heard dedicated colleague after colleague describe forgoing their lunch breaks in order to pack more and more into their overloaded days. Afterwards at the bar someone asked me if I felt guilty. My immediate response was “no”. After all I have been brought up to believe that the hallmark of a civilised professional life is having time to think. However the question intrigued me – should I feel guilty? Or, more to the point, maybe I had revealed too much by making my psychopathy apparent especially as I often follow lunch with a stroll by the sea.

I've been in psychiatry now for around 20 years – since the millennium in fact. I was just finishing my specialist registrar training in 2001, as the Dome was being finished off.

Things were really bad back then. I remember we had people with schizophrenia living in the community. I mean — how naive can you get. There was a reason the asylums were built in the first place. There was a run of murders, people with schizophrenia killing innocent members of the public, the same public that had been selflessly trying to help them integrate back into the community, giving them jobs and self-respect.